The in-house NIH study will take over a year to complete. This will be an in-depth study of 40 patients. Over 126 researchers will be involved. Patients with Lyme disease will be used as a comparison group.

Dr. Collins and Dr. Koroshetz both stressed that they are interested in working with the community, and that they are listening to patients.

The protocol is a work-in-progress. A lot of bureaucracy is involved.

Ampligen may be studied in the third phase of the trial.

Future ME/CFS funding is determined on the basis of grant proposals, and subject to competition from other neurological diseases, such as Alzheimer's.

My Observations

Hollow reassurances

Dr. Collins stated that the NIH is serious about pursuing ME/CFS research. He asked the community to "stay the course" on more than one occasion, and stressed that the protocol was a "work-in-progress." While Dr. Collins may sincerely believe the NIH is serious about its pursuit of ME/CFS research, what emerged from this teleconference belied the claim.

The ad hoc nature of this study, among other things, undercuts the claim that the disease is being taken seriously by the NIH. This is an exploratory study, which, while useful in the discovery phase of researching a disease, is untenable after 30 years of research have already been published.

The popular belief that no good ME/CFS research has been done over the past three decades, and that there have only been pilot studies, or that studies have been poorly designed, and that there have been no consistent results is one that has been promulgated by the NIH itself through the P2P Workshop and repeated ad nauseam. However, a close examination of the PubMed database reveals that there have been many well-designed studies, some large-scale, showing consistent immunological and neurological abnormalities, performed by people who are experts in their field.

With the amount of knowledge that has been accumulated on immune, endocrine, and neurological dysfunction (not to mention cardiac, muscle, and metabolic abnormalities) this is not the time to go on a fishing expedition. If the NIH was truly serious about establishing the biological causes of the disease, it would build on the research that has been done and appoint experts in the field to positions of authority rather than people with limited knowledge and experience in ME/CFS.

Study Design Flaws

Very little was said about the actual study design, which is probably because the NIH doesn't have a design in place. However, Dr. Collins stressed that NIH has a "world-class Clinical Center" and Dr. Nath pointed out that invited speakers would give them "cutting-edge knowledge and state of art techniques."

Ignoring for the moment the fact that inviting researchers to give talks is a far cry from actually possessing that knowledge oneself, and that simply having a "world-class" clinic does not compensate for an ineffectual study design, the idea that study designs can be built by people who are "making it up as they go" is rife with problems.

For example, the 2-day CPET will not be used in this study. This is an omission that will likely doom this study from the start, because, as Staci Stevens, Chris Snell and their colleagues have discovered, it takes a second exercise challenge to produce the anomalies characteristic of this disease. Given the study's goal of examining the biological consequences of exertion, there is no justification for the NIH's failure to use this "cutting-edge knowledge."

The second study flaw that has become apparent is in the cross-sectional nature of Phase I of the study. In this phase, Dr. Nath states that if there’s evidence of inflammation they will surely find it in cytokines.

Studies dating back to the early 90s, have found evidence of inflammation, and countless others have found immune abnormalities, including the recent cytokine study by Mady Hornig's group. There should not be an "if" because neuroimmune anomalies are a given in this disease.

Another study design question that arises is, why examine and test patients sequentially? Dr. Nath says it will take a week to test each patient. With 126 researchers and a "world class" clinic, why can't patients be processed simultaneously? It would certainly speed things up.

And yet another question was raised by Jennie Spotila, who asked why Lyme disease patients were being used as a comparison group. It makes better sense to use a group that has a truly resolved disease process, the flu, for example, rather than one which may or may have not have completely resolved.

Dr. Nath answered that question by saying that it was a matter of convenience. The NIH already has a lot of information on Lyme disease, which they can use for this study. He also stated that most healthy individuals recover from Lyme disease, which seems to imply that those who don't were not healthy. Nothing could be further from the truth. People who have contracted Lyme disease, and not recovered, were perfectly healthy. And as evidence is increasingly showing, people can recover from Lyme disease, and then relapse. (Borrelia burgdorferi is notoriously difficult to eradicate - even in a test tube.)

Dr. Walitt chimed in to say that because of the characteristic rash associated with Lyme disease, it is easy to pin down "exactly when the infection started." However, up to half of the people who contract Lyme disease either don't get a rash, or don't notice it. (This is especially true when the tick bite occurs on the head, or when the person has dark skin.)

Not only is Lyme disease a poor comparison group on the basis of the many unanswered questions surrounding it, the clinical investigators appear to have as little understanding of Lyme as they do of ME/CFS.

Bias and Implausible Deniability

One of the questions raised in the Q&A session by Lily Chu and Wilhemina Jenkins was that of bias.

Both Dr. Gill and Dr. Walitt have expressed the viewpoint that ME/CFS is a psychosomatic entity, by which they mean it is psychogenic and/or is perpetuated by psychological states ("illness beliefs"). Dr. Gill has advocated both graded exercise (GET) and cognitive behavioral therapy (CBT) as effective treatments for the disease, and Dr. Walitt has published several papers proposing a psychosocial model (aka psychocultural, biopsychocultural, and other variations) for fibromyalgia and ME/CFS.

In response to Wilhemina Jenkins' question about bias, Dr. Walitt stated flatly, "I don't have a bias." He was obviously, and quite deliberately, lying. There is no "wiggle room" for interpreting Dr. Walitt's views, which he has not only published in more than one paper but stated directly in an interview.

Dr. Walitt's reply was that "if Chronic Fatigue Syndrome, Myalgic Encephalomellitus [sic - he was not able to pronounce the word "encephalomyelitis"] is all in your head, it’s only because your head is part of your body." This obscure statement does not contradict his opinion that psychological states produce the physical symptoms of fibromyalgia and ME/CFS. The idea that diseases can be produced and perpetuated by psychological or emotional states is part of Freudian mythology. and it has been promoted by psychiatrists as an explanation for ME/CFS since the 1970s.

The notion that diseases spring up as they become socially "fashionable" is an another idea that was popular in the early 90s, and it is one that has as little evidence to support it as somatization disorder. Yet, Dr. Walitt has unequivocally stated that fibromyalgia is a "psychocultural" construct" - something invented by politicians, rheumatologists, and patients who are exaggerating their symptoms.

In like fashion, Dr. Walitt states that an infectious trigger for chronic fatigue syndrome is something "whose validity is not answered by the scientific literature to date." This claim is not only unsupported, it reflects a preconceived notion of the illness. Bias is so clearly evident in Dr. Walitt's writings that the only basis for its denial is that Dr. Walitt believes his psychosomatic theories of ME/CFS are correct.

Science demands not only evidence, but the possibility of refutation. Psychogenic theories of disease cannot be proven, nor can they be disproven, because they belong to the realm of superstition, not scientific inquiry.

It would be wildly optimistic to believe that this type of bias - not to mention the stunning ignorance - of the NIH's chief clinical investigator won't affect the course of this study.

Future funding

In reference to funding further [extramural] research Dr. Koroshetz replied that "NIH has processes that ensure that research comes in and the most highly meritorious research is funded and that all groups have a fair hearing when they come in." He stated that this is a "tried-and-true" process.

Interestingly, this "tried and true" process has recently been found wanting. A February 2016 study by Johns Hopkins University Bloomberg School of Public Health found that peer review for NIH grants was no better than random selection. One of the study's authors, Arturo Casadevall, stated that the current system is "worse than awarding grants through a lottery."

Among other problems with grant selection, personal preference enters prominently into funding decisions. "When people's opinions count a lot, we may be doing worse than choosing at random," Casadevall says. "A negative word at the table can often swing the debate. And this is how we allocate research funding in this country." That explains a lot.

It explains why research proposals for ME/CFS have been consistently turned down, even when they come from researchers who are renowned in their fields. One word from someone who thinks ME/CFS is "all in their heads" is all it takes to throw a grant into the trash. They don't even have to read it.

Bureaucracy in Inaction

Dr. Koroshetz remarked that when it comes to research, a lot of "bureaucracy" is involved. Those may have been the most meaningful words spoken at this teleconference. Bureaucracy is what has driven the choice of "clinical experts" to oversee this study - not one of whom has clinical expertise in this area.

Bureaucracy has driven the choice to conduct an exploratory intramural study, rather than fund the focused, dedicated and knowledgeable experts who have been working in this field for years - some for decades.

Bureaucracy has driven the decision to exclude severely ill patients - who have been included successfully in other studies - and to omit one of the most clinically significant tests of the last decade.

And regardless of the reassuring words, promises, and pleas for forbearance, it is a blind, self-limiting, self-perpetuating bureaucracy that has forced the likes of Dr. Walitt upon us.

The email address to submit comments to NIH is: braininfo@ninds.nih.gov

You can also address questions about the study to: NIHME-CFSWorkingG@ninds.nih.gov

You can listen to an audiofile of the teleconference as well as read the transcriptHERE.

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Transcript

March 08, 2016, 9:00 am CT

Coordinator: Welcome and thank you for standing by. At this time, all participants will be on a listen-only mode until the question and answer session of today’s conference.

At that time to ask a question over the phone lines, please press star 1 and record your name at the prompt. This call is being recorded. If you have any objections, please disconnect at this time.

I would now like to turn the call over to your host, Marian Emr. You may begin.

Marian Emr: Good morning. This is Marian Emr. On behalf of the NIH, I would like to welcome you to this morning’s teleconference and to thank you for your great interest in participating in this discussion with us today.

Each will make very brief opening remarks and then we’ll open the phone call for your questions. Please be patient with us through this process. We will try to get to as many questions as we can in the time we have available to us this morning. Now Dr. Collins.

Dr. Francis Collins: Thanks and good morning everyone. I wanted personally to join this call to thank you for joining us for what I hope is an ongoing conversation about ME/CFS and how we can move the needle forward together on characterizing the cause of this perplexing disorder to help with better diagnosis and treatment.

I want to assure you that from the perspective of the NIH Director, that this institution is very committed to this area of research. Speaking for many of us, we want to move the research agenda forward here both in terms of intramural activities -- which you’ll be hearing about -- and extramural research programs as well.

I’m happy to tell you that with regard to the intramural effort, we have received IRB -- that’s Institutional Review Board -- approval and expect to be able to launch this study at the NIH Clinical Center and then begin to enroll individuals this summer.

I have great confidence in Avi Nath, who’s the principal investigator, who’s going to speak to you here shortly, who will lead this important study. And he can tell you more about it.

A Web site describing the intramural protocol actually went up this morning. If you haven’t seen it yet, this will give you a lot of the details about the design of this study and how it’s going to be conducted.

And I think this is a remarkable opportunity to try to bring the whole power of this really remarkably, interdisciplinary research hospital to bear on this set of serious questions about what are the causes of ME/CFS.

There’s a lot of heterogeneity of course in this condition. The choice here was to focus on individuals who had previously good health and then a clear-cut onset in the context of a flu-like illness, in order to limit the heterogeneity and provide us with a better opportunity for getting answers.And we believe that this study in the world-class Clinical Center of NIH has the opportunity to provide some new insights that could be transformative for all of those who suffer from this condition.

So in addition, on the extramural side, a vigorous, reinvigorated Trans-NIH Working Group is working to define the strategic areas of research that would form the basis for a request for applications to the extramural community, both in the short-term and in the longer term.

And Dr. Koroshetz can tell you more about where we are about that particular set of discussions. We’re quite serious about looking for opportunities to expand our research in this area and to recruit new investigators into the field, bringing new eyes and new brains into the issue of trying to understand the puzzling aspects of this, that previously have eluded us.

So please take our commitment with great seriousness. Please also stay the course with us as we seek to identify the most compelling research questions and how we could address those.

I understand many of you have waited a long time, perhaps, to see this kind of attention. I hope you understand how much we are now looking at this in a very serious way and seeking to come up with some of those answers.

So if we can work together on that and not work apart, I think we have a much better chance of making real progress. We are your partners. We want to hear from you.

That’s why we’re having this call today. And we’re listening carefully to the comments and the suggestions you might have about how best to move this effort forward.

So that’s mostly what I wanted to say by way of introducing the call. I now want to turn this over to Dr. Walter Koroshetz who, as you know, is the director of the National Institute of Neurological Disorders and Stroke.

Walter is a neurologist -- a very experienced one -- and he has seen firsthand how devastating ME/CFS can be for patients. And he volunteered to chair this Trans-NIH Working Group and is working closely with other institute and center directors to promote research on ME/CFS.

And I want to say thank you to Walter for stepping into this space, and already with considerable vision, figuring out ways that we can make the kind of scientific contributions that this field very much needs. Walter, the floor is yours.

Dr. Walter Koroshetz: Thank you always Francis and again, I’d like to thank everyone for getting on. And I’d like to thank everyone for the expressions of interest and even the concerns that people have sent to us.

We are very interested in working together with the community to achieve our long-term common goal. And I think that common goal is shared unanimously, which is to find better treatments for people who are suffering with ME/CFS.

And I can just - like to start off by talking about the big picture - the intermural research protocol, I think, is one step but only one step in the trajectory that we need to get on to get answers that are going to be very helpful for patients.

And so this is, I think, a long-term quest. This is a difficult problem. I think if it was not difficult it would have been solved long ago. So I think we need to kind of get out there and bring in the best and the brightest from many different areas of science.

I don’t think we know where the solution is going to come from. So I think we need to cast a wide net, get involved a number of very experienced researchers and clinicians and work carefully with the doctors who are taking care of the patients.

As Francis said, I think the important thing is to stay the course and to look always to the long-term goal. At NIH, we have some bureaucracy which is not easy to understand.

But I would like to simplify it if I could that there is basically an extramural program, and the extramural program - you know, funds that go from the NIH out to universities, companies, other institutions to do research.

And there’s the intramural program where research is done at the Clinical Center in the Bethesda area. The Clinical Center is the world’s largest research hospital and really our only research hospital.

It has tremendous resources, but 90% of the funds from NIH go out to the extramural community. So in the long run, what we need to do is to engage both the extramural and the intramural community.

And you’ll hear about the intramural protocol which is starting up, but you also heard mentioned from Dr. Collins that we have a Trans-NIH Working Group. As I mentioned, we don’t know where the solution for this ME/CFS problem is going to come from.

So it’s very important to have the scientific input and the funding resources of multiple institutes at NIH to bring them to bear on this problem. The Trans-NIH Working Group has representatives from all the institutes and is working to develop plans that will move funds to very worthwhile, highly meritorious research proposals in the extramural community.

And we have the intramural program protocol which is going to be run by Dr. Nath. With that I’d like Vicky Whittemore to briefly describe the Trans-NIH Working Group and what it is about and thinking of doing in the short-term and the long-term. Vicky?

Dr. Vicky Whittemore: Good morning. This is Vicky Whittemore and I’m a program director at the National Institute of Neurological Disorders and Stroke. And I also would like to thank all of you for being on the call this morning.

I’ve been working with Dr. Koroshetz to coordinate the Trans-NIH Working Group and I have to say it’s really been a pleasure working with representatives from the staff of the 23 institutes and centers who make up the Working Group.

Everyone’s really dedicated and passionate about what we’re doing and what we’re working on. We are in the process of putting together as Walter said both a short-term plan, where we can try to activate some research on the shorter-term as well as initiative that would put in place better infrastructure as well as research funding for longer-term research projects.

And some of things we’ve been talking about -- clearly as the community has communicated to us as well -- the priorities of developing and identifying biomarkers for the disease, really understanding the underlying causes and mechanisms that lead to ME/CFS as well as getting a handle on and understanding what is causing what patients refer to as brain fog or the cognitive symptoms that many individuals with ME/CFS experience.

So our timeline is that we’re working very hard to put this plan in place and to present our initiative to the appropriate council for approval in the May timeframe and we will - to move forward with the initiative soon after that.

So we will be looking for input and feedback from the community. And I think several ways that we’re thinking about doing that is to put out specific requests to the community for feedback on ideas we have and things we’re thinking about, to have additional follow-up conference calls after this one in due time.

As well as to reach out to the research and clinical community to get feedback from them as well in terms of what we’re thinking and planning. So with that, I’ll turn it back over to Dr. Koroshetz.

Dr. Walter Koroshetz: So I just want to clarify one thing because I’m sure people are wondering out there why can’t we actually say what we’re thinking. And so it is important to understand that NIH has processes that ensure that research comes in and the most highly meritorious research is funded and that all groups have a fair hearing when they come in.

So what we can’t do is we can’t put information out before it’s ready to be made public to everyone. So that’s why we have to do a lot of work behind-the-scenes before we can make things public.

So it’s a kind of something that’s idiosyncratic, but it has its real purpose in presenting a fair and open process here at NIH. And that now I’d like to say also that as I mentioned before, I think it’s going to take an army of really good researchers to solve this problem.

I think that army has to work together. It can’t be individual groups working in isolation. So what we’d like to do is to form a consortium really of investigators who are working hand in step.

Not all doing the same thing, but a lot of innovation. And the first horse out of the gate is the intramural program. So I would like Dr. Nath, if he could, to try and briefly describe what the intramural protocol is all about. And I would add that Dr. Nath is calling in from Liberia where’s he doing fieldwork in Ebola.

And so we’re very gratified that Avi can get on the call and we hope that his line stays stable from Africa. Avi, would you like to describe the intramural protocol?

Dr. Avindra Nath: Oh thank you very much, Walter. This line should be fine because I’m using one at the U.S. Embassy.

Dr. Walter Koroshetz: Okay. Good.

Dr. Avindra Nath: So well thank you very much. So, you know, I’m delighted to be the principal investigator of the intramural study. And when Dr. Collins and Dr. Koroshetz asked me to consider this responsibility, I was actually very thrilled to be able to look at the syndrome and see if there is an immune or neuroimmune component here that may be driving the disease.

That is an area of my expertise. I have firsthand seen a lot of patients with the disease and know exactly how devastating it can be. And so, when I looked at the literature, it was very clear to me that there are very good reasons to believe that this is likely immune-mediated.

And so I designed a protocol that would address those kinds of issues. So the proposal I put together has three phases to it. The first phase is a cross-sectional study and that’s the protocol that’s on the Web and all the information that many of the groups have received.

However, and in in the plans is our second phase study. The second phase study would be a longitudinal study which will follow patients over a period of time with repeated testing but only with a small subset.

The first phase study has a lot of various kinds of investigations we will do. And then we’ll identify the ones from there that look most promising. And then in the second phase study, a much larger population, different types of population and then be able to study them over a longer period of time.

And then the third phase would be an intervention study. So based on the information that we gathered from the first and second phases that will guide us as to what kind of immune-modulatory therapy would have the best opportunity of making a difference in this patient population.

So that in summary is what we were thinking about as our goal towards developing a research protocol for a chronic fatigue syndrome.

Dr. Walter Koroshetz: Thanks very much Avi. Can you still hear us all right? Okay. So now I think I’d like to turn to Brian. Brian Walitt is a medical officer at the National Institute of Nursing Research.

He’s had considerable clinical and research experience in fibromyalgia and ME/CFS research. And he’ll serve as the lead associate investigator to help Dr. Nath coordinate the activity of a large number of investigators who will be involved in the study at the Clinical Center.

So Brian, do you want to tell us a little bit about what brought you to this really interesting protocol?

Dr. Brian Walitt: Yes, sure. Thank you Walter. Hi, I’m Brian Walitt. I am the lead associate investigator on the intramural protocol here at the NIH. My experience with all of this starts in my career in rheumatology where I had a lot of experience with hospital immune disorders and developed a specialization in fibromyalgia and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.

My interest in the disorders grew over time and led me to open a research clinic at Georgetown University where I saw patients on a regular basis. My patients taught me just how real these disorders are.

They are not just in one’s head. They do not reflect some unconscious choice and it is not possible to simply push through the symptoms. I tried my best to help my patients and learned just how limited the options really are and why there is an urgent need for a restorative treatment.

One that would give patients their lives back. I promised my patients I would do my best to find better answers for them. This passion is what led me to come work at the NIH.

Since I’ve been here at the NIH, I’ve been learning the ways that research is done here. I’ve learned a great deal about science from the world-class scientists that I get to rub elbows with.

I’m very lucky in that regard. I am very excited to help Avi Nath facilitate the protocol. I believe it’s going to provide some important answers to the big questions of ME/CFS: the role of infection, the role of immunity and the role of neurology and the generation and perpetuation of symptoms.

We’re also going to try to understand exactly what the biology of post-exertional malaise is. I believe these things will move the needle forward as Dr. Collins said. And I’m very excited to be part of this.

Dr. Walter Koroshetz: Thanks very much Brian. So I’d also just emphasize that the protocol at NIH has 26 associate investigators in addition to Brian and Avi, and they bring this really incredible expertise to the table in the study of the patients with ME/CFS in this protocol.

And this ranges from very high-level neuroimaging to high-level ability to look at cytokines, autoantibodies and we have people like Leo Saligan in the Nursing Institute as well who has been looking at chronic fatigue in patients with cancer and rheumatologic disorders.

So we have a really quite an amazing group and it’s different than what you might see in a hospital on the outside because everyone here is full-time devoted to research.

And so the community of researchers is quite extraordinary. And also the tools that we have in the Clinical Center are quite extraordinary. Very difficult to bring a patient in who’s very ill for research at a hospital any longer.

But here we have an in-patient unit where we can study patients over multiple days, even weeks. So we’re hoping that the resources of the Clinical Center will allow us to do some very unique things.

But I would also emphasize once again that this is a stepping stone. This is only one piece of the puzzle. I think it’s a very important piece but what our intention is, is to coordinate it with many of the other pieces that we’re going to start initiating across the country.

And with that, I’d like to open the phone to questions now and we’ll do our best to answer them. And once again, if we are not able to answer all of the questions, they can be directed to a Web site: braininfo@ninds.nih.gov. So thank you very much and let’s open the lines. First question?

Coordinator: Thank you. We will now open the question and answer session. If you would like to ask a question over the phone lines, please press star 1 on your phone and record your name at the prompt.

To withdraw your question, press star 2. One moment please for incoming questions. And our first question comes from Robert Miller. Your line is open.

Robert Miller: Hi, good morning everyone. This is Robert Miller. I’m a long-time patient and advocate. And first I’d like to thank Dr. Collins, Dr. Koroshetz and team for taking this key first step in doing the Clinical Center study for ME/CFS.

I think it’s a long-time coming for this patient population. But I’d like to start off and address actually possible treatments and in particular the treatment Ampligen.

And I’d like to ask what homework has been done thus far regarding Ampligen and if there’s been any talk with the FDA, as this is the only treatment ever to be into Phase III trials for ME/CFS.

And that opening for this drug potentially could lead to this drug being our - or this patient population’s, AVT. You know, opening the door to pharma for much more research.

And most importantly it would give relief to many suffering patients. Thank you.

Dr. Walter Koroshetz: So thank you Mr. Miller. And, you know, indeed as I mentioned the goal that we’re all marching towards is to try to get a treatment. And clearly, to start off I think we are going to challenge our investigators to survey the area of therapeutics that have been tried in ME/CFS.

Others that might have been tried in other illnesses that might come into ME/CFS because those are more of the short-term wins should they be, effective.

Developing new therapies is basically a ten to longer process. So that is very important. And so we certainly at the NIH have open-door policy for people to come in and propose research.And we have certainly met with many investigators and even the Hemispherx Company people and they presented the data that they have from their previous studies. And so that certainly is something that we are taking into serious consideration.

As I mentioned earlier, there is a process at NIH for the funds to go out. So the process is, again, a peer review process where investigators submit proposals, they get looked at by the leadership and then they go out to a peer review system and they kind of poke holes to make sure that the best proposals get the funding from the American taxpayers.

So that’s the system that would have to be engaged. It’s very different from an industry system where the industry makes the decision to put the funds down and they take all the risks.

Here we’re working with taxpayers’ dollars and so the process is very important to uphold. But certainly we are looking at that and we expect that we’ll be having discussions on the clinical trials as they come forward. So thanks very much for that question.

Robert Miller: Thank you.

Coordinator: Our next question comes from Donna Pearson. Your line is open.

Donna Pearson: Thanks very much. So there is substantial confusion between the diseases that you’re studying and other conditions involved in unspecified chronic fatigue. And that confusion impacts research, medical education, diagnosis, treatment and care at every level.

And I know that the name is not an issue that many people want to talk about in research. However, a name is the single most obvious way to distinguish a disease from another disease.

I mean I wouldn’t clearly agree that a name change is appropriate. I’d suggest the establishment of a new ICD code. So my question is, does the current study and the tests that you will be doing have the potential to determine if encephalomyelitis is in fact an appropriate name for the disease?

Dr. Walter Koroshetz: I’m not sure if Avi is still on the line.

Dr. Avindra Nath: Sorry, I’m here. I’m here. Yes.

Dr. Walter Koroshetz: Okay.

Dr. Avindra Nath: So, we are not looking at every single aspect of the disease. We are looking at a select population. And in that population, we can certainly tell you if there’s evidence of inflammation.

And if there’s evidence of inflammation then I think it’s fair to say that if present, an inflammatory process in the brain.Whether we use the word encephalomyelitis, the problem is that you have to demonstrate there’s an infiltration of cells.

Just activation of immune system in the brain alone is not sufficient to cause encephalomyelitis. You can get activation of the immune system in patients with Alzheimer’s disease or Parkinson’s disease. We don’t particularly call that encephalomyelitis.

But I think we will get closer to that answer because we will be able to look at a panel of cytokines and we may have some suggestion as to what kinds of cells are producing the cytokines.

And so, yes we will get closer to that definition. Whether we are able to establish it beyond an element of doubt or not, it won’t be from this study. We are planning some animal studies and I think that it’ll be a better chance for being able to answer that.So the animal studies will take lymphocytes from the patients, inject them into the animals and try to reproduce the disease. If we can, then we can look at the brains of the animals and actually tell if their cells are infiltrating or not, if we produced the phenotype or not.

I think those kinds of studies have a much better chance of being able to answer the question that you addressed.

Dr. Walter Koroshetz: Let me just add a couple of points because I think they’re important to understand. And I’d say that the protocol at NIH is interested in trying to get at the biology, the biological basis of the illness.

Now eventually that might, the biologic basis of the illness in most of the illnesses is eventually what moves the definitions and allows break-up in the heterogeneity of a disorder.

It’s a particular biological entity. That process is a long process. And so, I would urge people to basically stay the course there. Clearly this protocol which is looking currently at 40 patients - what they find will then need to go into another stage to be validated in other groups of patients to make sure that it’s a real finding that can be generalized.

So generalizability is the next step that would come when a discovery is made. One reason we think it’s real important to organize ME/CFS researchers across the country is because many studies have discoveries but they’re never really validated to know if they’re generalizable.

And so, I think we have a lot clues in the literature but one thing we need to do is to make sure that they can be generalized across the population. And the expectation is, I think, that there are multiple, different types of ME/CFS.

And it may not, something we find here may not generalize. This protocol is for persons who develop the condition after a flu-like illness. There are other ME/CFS patients who develop the condition after other types of exposures.

Environmental exposures, allergic exposures, traumatic exposures. So we can’t solve the whole problem with this one protocol. This is, again, a piece of the puzzle. I urge people to think of it in that way. Okay. All right. Can we go to the next question?

Coordinator: Our next question comes from Cort Johnson. Your line is open.

Cort Johnson: Thanks. As I’m sure you’re aware that Ron Davis is taking on a similar exploratory study. And so what I was wondering was if it’s possible for Davis to follow-up on findings that you get and vice versa?

Can your team follow-up on findings that he gets? Is it possible to give him some funding to be able to do that? And my second question involves the exercise study.

Staci Stevens at Workwell has worked for years to develop standardized exercise protocols that work for ME/CFS patients. That exercise portion of the study is probably a critical part of the study. Is the team planning to contact her and work with her to be able to use a similar protocol in their study?

Dr. Walter Koroshetz: Okay. Brian, could you address the exercise protocol and then Avi, maybe if you could address the data sharing next?

Dr. Brian Walitt: So the exercise protocol for the study that we’re doing in the intramural program is designed to induce post-exertional malaise. Right? It’s a maximal effort exercise intervention.

It’s designed to provoke symptoms as opposed to being a treatment. The CDC, Beth Unger, has a lot of experience in doing this kind of work. And we’re going to be talking to them about designing proper ramps and so forth.

However, we are open to suggestions from all people with experience and we would be happy to reach out to others that may have useful things to add as we design the intervention.

Cort Johnson: Thanks.

Dr. Avindra Nath: This is Avi. Let me just add to that. So,I did talk to Dr. Davis and we are absolutely delighted to collaborate with him. The kind of study he’s doing is not exactly the same that we are proposing to do.

So I discussed that with him in great detail. We actually exchanged a number of...

Dr. Walter Koroshetz: Oops. I think we dropped off Avi. But I think his point is that that yes he has been in contact with Dr. Davis and actually a number of other investigators around the country who are collecting samples and they will be sharing data.

Now I think also as we mentioned, what we’re hoping to do is to set up a series of investigators around the country who can work in concert with each other and share data.

As particularly with regard to looking at the second issue I mentioned before, which is generalizability. If you find something in one group and you check another group that you think is similar, do you see those same findings or not?

Unfortunately the history of these kind of biomarker studies is such that it’s a lot of things fall out and don’t replicate. So you really need to do this coordinated approach to make sure that what you’re putting your money on is a real thing. A real finding.

Okay. Can we go to the next question?

Coordinator: Our next question comes from Charmian Proskauer. Your line is open.

Charmian Proskauer: Hi. Thank you very much for this opportunity to have a discussion. I think this is great. You may have already answered this question in part through things that you’ve already said.

But I’m going to ask it anyway. Why only 40 ME/CFS patients? I realize that this is a very deep study but with 40 patients does that have the danger of falling into the category of just another pilot study with numbers too small to be really meaningful? That’s my question.

Dr. Avindra Nath: So let me address that. This is Avi.

Dr. Walter Koroshetz: ...question...

Dr. Avindra Nath: So there are two aspects to it. Number one is we’re going to be screening patients. It’s going to take us awhile. And then when we admit the patients, they're going to be in for a week. So it’ll take us one patient per week.

So even if, you know, give or take 40 patients, it’s going to take a minimum of one year just to study 40 patients. Plus you’ve got the controls. So it’s going to take you a while to actually get through this population.

So if your entries are more and more, it’s going to take you longer to get to the answer. The other thing is that we’re selecting a very precise population. Within 40, there’s at least - calculated a lot sample sizes based on the information that we have.

If you don’t find a neuroimmune, you know, abnormality in 40, then it’s unlikely to be a major driver of the disease. And I’m pretty certain that this is a decent sample size for us to be able to find the kinds of immune abnormalities that we’re looking for.

So I think the sample size is pretty decent and it gives us an opportunity. And after that like I said, we’ll do a longitudinal study. So then you can enroll as many patients as you want from all over the country.

And other people can participate in the study and take those findings and look at multiple groups. So you have second phase of the study that allows you to do a more expansive study.

But you don’t want to do a huge expansive study the first time around. If it takes 1000 patients to find something, it probably isn’t worth chasing a result.

Dr. Walter Koroshetz: I think I’d also add that at NIH there’s a culture which is actually a try-and learn-as-much-as-you-can from every single patient. So there is, for instance, an undiagnosed disease clinic here where people come with diseases that could not be diagnosed on the outside. And they found causes for many of these patients.

They were all different though. So I think, you know, it’s also possible that with the kind of in-depth analysis that there may be very robust findings in even one or a small group of patients that will be very important. So it’s a little bit different - it’s definitely not an epidemiological study. The NIH is much more - it’s advantage is in deep study of small numbers.

But I think as the question you posed, the issue that to actually get the answer for all the patients who have ME/CFS, this is just one step and we have to see what we discover and how generalizable it is to the population.

And that’s going to require multiple steps and a larger group of investigators. Can we go to the next question?

Coordinator: Our next question comes from Joni Comstock. Your line is open.

Joni Comstock: Our focus is the severely affected patients, most of who are homebound and bedbound. Some are so sick they’re unable to care for themselves. We were dismayed to learn that the protocol and design for the intramural study has been well underway without any input from the ME/CFS expert clinicians, researchers, as well as from the patient and advocate community.

This became even more disturbing as so many flaws were revealed about the study. These deficits showed us that many of the ingrained agency misconceptions of the disease still exist and have not been clarified.

Therefore, we initiated and delivered a petition with 725 signatures to Dr. Collins, to stop the study and start it from scratch with stakeholders input from the get go.

Because of ingrained institutional misconceptions, whether deliberate or not, we expect the NIH to engage the expert community on any ME/CFS study from the moment of its inception.

They should have input throughout the entire process. This is includes the planning and implementation of the design, recruitment, trial, analysis, study outcome, peer review publications and the publicity.

Do you intend to respond directly to MEadvocacy about the petition and how do you plan to incorporate our concerns?

Dr. Walter Koroshetz: Well let me just start and I appreciate your concerns. And our intent is to reach out and get input from a wide variety of folks with expertise and with experience in this illness.

And we have been doing that right from the beginning at NIH through the Trans-NIH Working Group, through the CFS Advisory Committee. We’ve had multiple meetings with experts in the field and with advocacy groups. And I must say it has been a challenge for us because there are, well we may not have reached out to everybody.

And we apologize for that. But it’s been very difficult to know exactly who everybody is and that’s the reason we have these calls and this is not going to be the last of our calls.

But it’s only the beginning. And we will learn from patients. I think the history of medicine is that as you work with patients, the patients teach you lessons.

And so, I think that the major teachers at the NIH really have to be the patients who have made the sacrifice to join the protocol, to come into the Clinical Center and to work with the doctors.

I think that’s where a lot of the input is going to come. And the protocol itself, Brian can correct me if I’m wrong, but the protocol is always a work in progress. So a protocol gets put up. It has to get approved. Then it moves forward.

Then there are amendments that have to get approved again. Then it moves forward. And the protocol is something that’s going to have to be tested.

It’ll probably be bringing in control persons to see if they can manage the protocol as it stands before we bring in patients with ME/CFS and put them through the protocol as it stands.

So I think we are definitely interested in getting input. But in truth of the matter, the scientists at the NIH, they have to be the ones who are empowered to work with their patients to try and get at the bottom of what is the biologic nature of ME/CFS.

So we are very interested to move ahead and we can’t take all patients with ME/CFS or the very severe cases who are homebound, I think would certainly not be wise to start there. I don’t know - Brian, if you have any points on that.

Dr. Brian Walitt: You know, part of the protocol is to look at post-exertional malaise which requires pushing patients a bit and being able to exercise and being able to do things.

Taking a homebound population and stressing them more may lead to untoward consequences for the patients and we need to be concerned about those things. It’s definitely a very important population to study but that might be for the next phase.

Dr. Walter Koroshetz: Right. And I think, the Clinical Center does have the ability to bring people into the hospital who are in very poor condition because it is a hospital and has 24-hour nursing.

So it is something that we could potentially get to at some point. But I think it would be probably unwise to start there. So again, I apologize to the community for the perception that we’re not listening because we are very much listening.

And we will continue to listen and we will continue to communicate best we can. So thank you very much for that. Could I have the next question please?

Coordinator: Our next question comes from Lily Chu. Your line is open.

Lily Chu: Hi, good morning. This is Lily Chu. I was one of the co-authors of the IOM Report. I’m also the co-Vice President for the International Association for CFS/ME.

But my comments today are my own individual views. So I have two points. One is about the study itself and the second is about staff. One of things I found when I was reviewing the literature for post-exertional malaise is a lot of the literature only looked primarily at fatigue as a symptom.

And I’m trying to review the Web site you have up right now and again, it says that you’re going to have a diary of people recording their symptoms for at least a week once they’re back home.

And that’s good. But it says fatigue symptoms. So what I would suggest is, you know, PM is more than fatigue. And in our report we talk about things like people having problems thinking, people having problems sleeping, sore throats and enlarged lymph nodes, allover muscle pain.

So what I would suggest is that you ask for more symptoms than just fatigue and that you leave some open-ended areas where people can put in their symptoms.

The second thing is timing. So most studies, they just take a period like two days and that’s when they collect their blood tests or their other tests and their symptoms in patients.

And what I was finding from reading the literature, talking to patients and some data I have that I’m analyzing right now is that timing of PM can vary a lot.

So ideally, it would be nice if you could time the test to when people are saying this is the peak of my PM or even like have it after one day or two days.

Because sometimes people’s PM does not start until several days after whatever the triggering event is. In this case, it looks like you’re doing a treadmill to induce the PM.

So that’s my point about process. The points about staffing, I’m really glad that you have some experienced people on this project, including Dr. Lipkin. But one of my concerns is that you have both Dr. Walitt and Dr. Gill on this staff.

And I’m sure you’ve heard a lot to some degree already about Dr. Walitt. My concern about Dr. Gill is back in 2011, he did a talk for NIH and he had a lot of slides in there about pacing and about, not about pacing but about graded exercise therapy, cognitive behavioral therapy and about not ordering certain tests.

Like for example, tilt-table testing because they weren’t suggested by the CDC at the time. And so there are some concerns there -- I can send you links -- where a lot of the community had concerns about Dr. Gill and I even wrote Dr. Gill a letter before his talk.

I’m hoping his views have evolved and changed since then. So if he’s changed that’s great. But I have a little concern about that. Even if you have the right people for liking the patients, if the people interpreting the studies have certain biases - and we all have biases - but those need to be recognized when they go into and analyze or interpret the study.

So I’m wondering if the staff that’s on the study, are they going to be reading things like the IOM Report, the NIH Statement of Knowledge Conference Report from 2011 even and the ARC and NIH reports more recently? Thank you.

Dr. Walter Koroshetz: Thanks very much for that. I’m going to ask Brian to talk a little bit about the protocol with regard to the symptoms you mentioned, the trying to peak, and then the docs working on the protocol.

Dr. Brian Walitt: So that’s a very good point, that what exactly post-exertional malaise is has been poorly explored to-date. What we’re going to try here at the NIH is to induce it and describe it as it happens.

This will be done qualitatively by speaking with the patients and listening to what they have to say and hearing their descriptions of it. We may even do a qualitative study of the words that are used to describe it.

As well as biologic measurements that are taken sequentially starting before the exercise and following it over the course of their hospitalization. And the hope is that we’ll be doing all sorts of different biological measurements to try to capture different aspects of the biology of post-exertional malaise.

And so your comments about timing are very true and we are taking that into consideration.

Dr. Walter Koroshetz: Great and thanks for very much.

Dr. Avindra Nath: Dr. Koroshetz, this is Avi. So, throughout the protocol there will be continued seminar series, journal clubs, so on and so forth.

So that the team that is working on the protocol becomes well aware of the existing literature, the emerging literature, the pros and cons and the critiques of previous protocols and previous studies as well.

We’re going to have invited speakers come and talk to us so that we have a cutting-edge knowledge and state of art - the techniques that we are using in order to study the syndrome.

And that’s how we conduct all our other protocols. So that’s no different than we would do for my other protocols as I would do for this. The other thing is the way I’ve designed the study, there is no element of subjective bias because really what I’m looking for are immune abnormalities, where they’re going to be done in my laboratory, they’re going to be done in the Center for Neuroimmunology.

And although there are 26 investigators there, there are about, if we include the people in various laboratories and others that are doing the study, there are over 150 people.

So there is a huge number of people doing things in the study. I ultimately interpret all of these things. And then we will, you know, make the findings available to everybody.

And there’s an advisory group that looks over our study as well as our findings. So I’m not really concerned...

Dr. Walter Koroshetz: Right. So Avi dropped off again, but I think the point is that the NIH is a very unusual place in that the people here try and get at the bottom of problems.

And they have really the strictest scientific minds and I, rarely if ever, have seen what you might call a personal bias affect the study. So I think everybody here is really devoted to just getting to the bottom of the problem.

And I really do not see any chance that this is going to be corrupted at all. It’s a very unusual place where there’s very little incentive and actually it’s a career-breaker if that ever happens.

So I really do not feel that this is a concern that the community should worry about. But thanks very much.

Dr. Avindra Nath: And the design of the protocol is not going to allow any of that anyways.

Dr. Walter Koroshetz: Yes. Right. Okay. Great. Can we go to the next question?

Coordinator: Okay. Once again as a reminder to participants to ask a question over the phone lines please press star 1 on your phone and record your name at the prompt. Our next question comes from Jennifer Spotila. Your line is open.

Jennifer Spotila: Thank you and thank you -- excuse me -- to everyone on the panel, especially Dr. Collins. I appreciate your personal appearance here today. I have as you can imagine a million questions. I’m going to focus on three.

The first question for Dr. Koroshetz, can you make a commitment to this community today that a request for applications with set-aside funds is going to be part of the short- and long-term strategy coming out of the Trans-NIH Working Group?

My second question for Dr. Nath or Dr. Walitt is why the selection of Lyme disease as a comparison group? There’s a lot of overlap in the chronic Lyme community and the ME/CFS community.

People being diagnosed with one when they may have the other and also there’s a question about reliability of the testing. So if you were looking for a post-infectious group with no sequelae, I wonder why something like resolved influenza might not be a better comparison group.

And then the third question for Dr. Whittemore is how are you going systematically incorporate patient and subject matter expert input into this study and into the formulation of strategy?

I think these town hall meeting calls are a great tool for you to use but it shouldn’t be the only one. And I know I would really like to see some more systematic involvement of both patients and subject matter experts throughout the phase of the strategy. Thank you.

Dr. Walter Koroshetz: Thanks very much. Let me talk a little bit about the first question which was the commitment of funds and RFAs. So given the processes I mentioned at NIH, I can’t really say that.

I can tell you that that’s our goal. That’s what we’re working towards. And we’re hopeful. But I couldn’t say publicly what we’re going to be able to do until we have a plan that we can make public.

So I hope that’s helpful. In terms of the Lyme disease, Brian would you like to take that one?

Brian Walitt: Sure.

Dr. Avindra Nath: I can handle that. This is Avi.

Dr. Walter Koroshetz: Avi? Okay.

Dr. Avindra Nath: So the reason I asked for the Lyme disease group is because there’s two reasons for it. Number one is it’s a patient population of convenience for us because Adriana Marques, an infectious disease expert at NIH, has a patient population - she specializes in Lyme disease.

So she already has a well-characterized population of patients who we know that for certain had Lyme disease and they did get better or they did not get better. And so, we could very easily recruit from an existing cohort.

And so when we thought about working with these - we want a control population. This is not chronic Lyme disease. So that’s the other thing I want to make absolutely certain.

These are individuals who had an infection and that they did not develop any other chronic symptoms. They fully recovered. So in that sense that’s pretty close to a healthy normal, because normal individuals also develop infection at some point in time.

And most healthy individuals recover from it. But here, this is a specific infection, a sample size of individuals that already exists at NIH and we can easily recruit from them. They’ve already been studied at great lengths.

So we can actually use the information that already exists on them. So with all those things considering that’s why we chose this one. Not that the influenza population is not worthy of studying.

I think that would be fine too. But we picked this for the reasons that I mentioned.

Dr. Brian Walitt: If I can also add, the onset of Lyme disease has some very specific physical findings, in particular the rash of Lyme disease that helps us understand exactly when the infection started.

And so when we’re trying to look at people that are after the infection, it makes it easier to figure out actually when the infection started and pin down the time.

Dr. Walter Koroshetz: Great. And Vicky, do you want to talk a little bit about engagement of the community as we move towards extramural plans?

Dr. Vicky Whittemore: Sure. So for the involvement of the community with the Trans-NIH Working Group, we’re thinking about initiating a period of time with each of our working group meetings when we can open the lines and have input and/or potentially presentations from various members of the community.

Again, using our Web site to push information out and also to get feedback from the community would be really helpful. And I think we’re also always open to any thoughts that the community has.

We’re thinking about some workshop ideas where we would involve the patient and clinical and research community in the organization and putting that together and also then welcoming patients to attend that meeting.

Dr. Avindra Nath: Yes. Can you say that question again about involving patients as advisors or involving...

Dr. Brian Walitt: Yes, I think she was asking about the patient advisory group Avi. Yes.

Dr. Avindra Nath: Oh okay. All right. Okay. So we looked into some of the legalities about patient advisory groups and it’s a little bit complicated in the federal government.

But nonetheless, what we are absolutely committed to is getting input from patients throughout the study itself. So I think some input we’ve already received and we’re going to come up with a system whereby we can get continual input from patients and patient advocacy groups as our study moves forward.

As Dr. Koroshetz mentioned earlier, the protocol is a process and evolution. Just because you wrote up a protocol doesn’t mean that’s exactly the way it will be conducted.

There are a lot of changes that occur through the process. And so continual input is necessary throughout the life of the protocol. And so, we’re happy to receive that and we’re happy to work with the patients and the advocacy groups for that purpose.

Dr. Walter Koroshetz: I think that also the patients who are enrolled are going to have a lot of influence on the docs and how it moves forward. Okay. So thank you very much. Can we go to the next question?

Coordinator: Our next question comes from Wilhelmina Jenkins. Your line is open.

Wilhelmina Jenkins: Good morning. I’d like you to especially thank Dr. Walitt for being here. And I understand that Dr. Nath spoke specifically to the importance of keeping personal bias out of any research that goes on.

But I wonder if Dr. Walitt, just to allay the fears and concerns of the community, could speak directly to that himself. And I’m sure you understand the fears of the community based on many studies that have taken place, particularly the PACE studies in England.

That we are very concerned about that problem of bias within a study. That is has been shown to affect the results. I understand Dr. Walitt has worked with patients and I would just like to hear him speak again about how his own view of this illness will be incorporated within this study or will not affect this study.

Dr. Walter Koroshetz: Thanks very much. Brian?

Dr. Brian Walitt: First let me affirm by saying that Chronic Fatigue Syndrome, Myalgic Encephalomyelitis is a biological disorder. Research has shown that in every system of the body that has been investigated that there have been abnormalities when compared to healthy volunteers.

If Chronic Fatigue Syndrome, Myalgic Encephalomyelitis is all in your head, it’s only because your head is part of your body. In regards to my individual role in this study, I am certainly a facilitator of research hoping to coordinate all the scientists and all the medical professionals that we require to make this happen and to help provide care and to be a cheerleader for the patients as they come through the protocol.

I don’t have a bias and I don’t have the outcome that I hope to see except that we find an answer that makes people better.

Dr. Walter Koroshetz: Great. Thank you very much Brian.

Marian Emr: We have time for one last question.

Coordinator: Okay. It’ll just be one moment.

Marian Emr: Then let me just fill the gap by saying I know there are others of you waiting to ask questions of us. Please, thank you for your participation this morning. And send us those questions.

Please send your questions to braininfo@ninds.nih.gov and we will make our best effort to respond to you in a timely manner. Thank you again for participation. One last question.

Coordinator: And our final question comes from (Deborah Waroff). Your line is open.

Coordinator: We’ll skip to the next question. The final question comes from Rivka Solomon. Your line is open. Rivka, you currently have an open line.

Rivka Solomon: Hi, sorry I was on mute. Sorry. Can you hear me now?

Dr. Walter Koroshetz: Yes, very well. Thank you.

Rivka Solomon: Okay. Thanks. Thank you very much for holding this meeting today. So I’ve been sick 26 years, much of that homebound and bedridden. And it’s obviously devastated my life and at least a million other patients are suffering with this illness in this country.

I think that we need equitable research funding at a level that’s commensurate with the degree of disability and with the population numbers. I know this is a first step you’re saying, but in my mind and in many patients' minds we need probably something along the lines of $250 million a year to be able to address this illness properly.

And that doesn’t even count the 30 or so years that we’ve missed. So could somebody address that please?

Dr. Walter Koroshetz: Thanks Rivka. Yes, I think for this as unfortunately as well as many diseases, the amount of research funding does not match the burden of illness. In our institute, we have probably 300 different neurologic diseases.

And that’s the case for every single one of them. That being said, the process by which NIH deals with how to allocate these scarce resources is a tried and true process that’s been in place for 50 years where investigators submit grants, they get peer reviewed and they get scored.

And then the NIH starts to pay the ones that seem to be the most highly meritorious and go down the list until we run out of money. So the system is a peer review system and what we need in some diseases and I think in ME/CFS, we need funds to formalize the research, to get the research going.

To get really a large number of highly motivated and well trained investigators into the field, and that’s what we are planning to do in the fairly short time, is to try get that growth of investigators.

But the truth of the matter is to really get the funds towards ME/CFS to a higher level on par with many other like-diseases, we need those kinds of applications to come in and compete against -- and in a fair way -- with the other disorders.

And so I think as a short-term process that we definitely have to stimulate with funds that are particularly for ME/CFS and Dr. Collins is clearly behind that. But our hope is that this will actually spread.

That the community will come in and begin working with investigators at universities and clinics throughout the country.

And that groups will form that will submit applications that are clearly incredibly important and a high level of science that gets to the bottom of the problem.

So I think, again, we have to utilize the NIH resources as best we can for the long-term and I think we can do that. But we cannot do it alone. We need to do it with the patients and the advocacy groups together, working hand in hand as we try and fight this illness. So I want to thank everyone for coming on.

We’re out of time. We will certainly be looking at the questions that get submitted and we will, again, set up another call where we can continue the dialogue that we started today.

And I can’t say how much everyone around the table and Dr. Collins appreciates the interest and the concerns of the community. It’s really been fantastic. So thanks very much.

Marian Emr: Please send any of your unanswered questions to braininfo@ninds.nih.gov. And for those of you who aren’t near a pencil and paper, you can go to the main NIH ME/CFS Web site and simply click on contact us to submit those questions. Thank you again for a very productive discussion this morning.

Coordinator: Thank you for your participation in today’s conference. You may now disconnect.

Maryann fell ill on March 2, 1982, at 10:00 pm while a doctoral student in philosophy. Maryann was athletic and a high achiever before she fell ill with ME. She rode show horses and was on the high school swim team. She was a water safety instructor. She traveled the world and knows four languages. Maryann continued to work for years after becoming sick with ME. Much later she developed many complications and since 2009 she has been considerably worse.

When Maryann became too sick to work teaching philosophy, she worked as a writer. She focused on studying science and has been a strong voice for others with the disease. Maryann founded the ME Society of America –- the very first in the USA to adopt the name of ME. Her purpose was to give patients access to scientific literature on the pathophysiology of ME to which they could refer their physicians, keeping her sense of responsibility to others at the forefront of her activities. Her website provides links to published articles by researchers and clinicians demonstrating the biological reality of the severity of ME.

Maryann's efforts in collating good research have been a wonderful treasure to many sufferers, especially the young and their carers and physicians. Recently, she wrote a speech that was delivered by a fellow advocate at the Institute of Medicine meeting on ME in 2013.

Maryann’s friends know her to be a person with a knife-edge mind, a quick wit, a strong sense of irony and a will of steel. She has persevered against unbeatable odds and countless life-threatening medical problems for the last 18 of the 34 years she has lived with ME. She attributes much of her successes and survival to open mindedness about treatments and sheer luck.

In the last ten years, Maryann has been quite ill but has remained stable in her home, but she has had to pay for considerable homecare costs out of pocket. She has depleted her savings from when she was working as well as a substantial inheritance from her parents in the process of paying for her care. She is at the end of her finances and will run out of money to pay her carers in only a few weeks. Due to co-occurring complications, without home care and other specialized necessities, Maryann is faced with terminal health repercussions.

Should she be forced from her home, the outlook for Maryann is grim. She is not well enough to move or be hospitalized. As her physician wrote in a letter to the home care program last October, she would suffer a “lethal relapse” of her disease if she had to move, be placed in a hospital, or forego in-home help.

This is our effort to raise money for her to pay for her caregivers. Only weeks remain if she does not receive immediate financial help.

We are asking you for whatever help you can give, so that this very highly regarded and well-liked human being who we call our friend can continue to live. Due to long-standing co-occurring diseases and without home care, Maryann is faced with a death sentence. Please help Maryann continue to fund her home care and help us avoid the loss of this dynamic, courageous individual. She has pursued every last option available to her in an effort to keep herself going.

When the NIH posted the protocol for its study on ME/CFS, it was immediately met with a storm of protest.

First, the protocol used the discredited Reeves (aka Empirical) case definition to establish its cohort of patients.

Second the tests seemed vague and far too general, as if the NIH were going on a fishing expedition rather than employing a focused approach.

Third, there was no mention of tests that would confirm that the staff was well versed in research performed outside the purview of the CDC. (The protocol has since been removed.)

In spite of Dr. Collins' repeated assurances that the NIH is taking ME/CFS research "very seriously," the FAQs posted on the NIH site (read them HERE) do little to allay the concerns of the community.

Walitt and Gill: Inherent Bias

Most disturbing, there is the question about the Executive Board of "clinical experts" chosen to oversee the selection of patients. This Board consists of Dr. Elizabeth Unger, Dr. Ian Lipkin, Dr. Leorey Saligan, Dr. Fred Gill, and Dr. Brian Walitt. While some of these Board members have been involved in research, not one of them has clinical expertise in diagnosing ME/CFS.

A further concern is NIH's appointment of Dr. Brian Walitt to be Clinical Director for the ME/CFS study. Dr. Walitt's views on fibromyalgia were presented in an interview he gave last September at the Perspectives in Rheumatic Diseases conference, held by Global Academy for Medical Education.

According to Dr. Walitt's interview, the pain experienced by people with FM is "normal,"

"These atypical things," he said, "are just a range of normal, that you are not sick, bad or weak, that you are just dealing with the difficulties of just being a human."

Dr. Walitt went on to say that there is no treatment for FM, therefore patients should "carefully consider changing their life narrative." (Practitioners of CBT call this "correcting false illness beliefs.")

While an interview may be subject to interpretation, the written word is not. In 2013, Dr. Walitt co-authored a paper with Dr. Fredersick Wolfe, entitled "The Changing Nature of Fibromyalgia." In that article he clearly expresses the view that FM is a "psychocultural" construct. He lays the blame for turning FM into an "illness" on rheumatologists, politicians, the "legal industry," and, most significantly, patient groups.

"The experience of child abuse," he concludes, "is associated with FM symptom severity and may shape the biological development of interoception in ways that predispose to pain and polysymptomatic distress."

In short, Walitt believes that emotionally unsound, middle-aged women exaggerate normal symptoms (such as pain) but that they have somehow convinced the medical and legal establishment that they have a "real illness" to justify their mistaken belief that they are ill. The remedy? They should learn to live with it.

Unfortunately, Dr. Walitt isn't the only member of the Executive Board to adhere to psychogenic explanations of ME/CFS. In a 2011 lecture held at the NIH, "Chronic Fatigue Syndrome: Is there a virus?", Dr. Gill expressed the view that ME/CFS could be successfully treated with exercise (GET) and therapy (CBT). (You can read the Mass CFIDS/ME and FM Association's summary of his lecture HERE.) Like Dr. Walitt, he compared ME/CFS to neurasthenia, a 19th century psychiatric disorder thought to be the product of overwork and "stress."

The inclusion of two staff members who do not believe in the biological underpinnings of ME/CFS on a project professing to identify biological underpinnings is absurd. They are predisposed to ignoring biological evidence, as has already been shown in their presentations, talks, and papers. How can NIH seriously consider including these two men on this study?

I have written to NIH requesting that both of these men be removed (see below). Feel free to write the NIH yourself, and to use my letter as a template.

Address your email to: braininfo@ninds.nih.gov

____________________

Dear Dr. Koroshetz,

I have read about the NIH ME/CFS research study with great interest. This study is important, not just for identifying the cause of ME/CFS, but for all future research, and therefore must be designed and conducted with the greatest of care.

Dr. Nath has expressed the opinion that because so many people are involved in this study individual bias would be impossible. However, on your research study FAQs, you list Dr. Gill and Dr. Walitt as two of five staff members who will make final assessments of diagnostic validity.

Dr. Gill has gone on record as recommending graded exercise (GET) and cognitive behavioral therapy (CBT) for patients with ME/CFS. Both of these treatments stem from the "psychosocial" model held by psychiatrists who believe ME/CFS to be a form of hysteria ("conversion disorder"). Dr. Gill has also compared ME/CFS to neurasthenia, a 19th century disorder that bears only passing resemblance to ME/CFS and is widely considered to be a form of anxiety.

Dr. Walitt has professed a similar view of fibromyalgia and its related illnesses (e.g. ME/CFS). In a paper published in 2013, he stated that “Fibromyalgia does not fit the definition of a categorical disorder, but represents the end point of a continuum of polysymptomatic distress. The evidence for a psychocultural disorder is strong.” He has stated in clear terms that patients experiencing the pain of FM are simply exaggerating "normal" symptoms, and that they should change their "life narrative" rather than seek treatment.

As staff members making final assessments of diagnostic validity, Dr. Walitt and Dr. Gill are in a position of relative power and authority over other staff members and investigators. Their view on the illness as being psychogenic will undoubtedly influence their decisions. Both are biased and should not be involved in this project.

This second part of the session consists of a presentation by Dr. Avi Nath, the neuroimmunologist who is heading the NIH study on ME/CFS. The last 10 minutes of the session was opened to questions from the floor, during which Dr. Nath supplied more details about the study.

Main points in Dr. Nath's presentation:

Phase I of the trial will involve 40 patients. This will be an in-depth study, and will take about a year. NIH hopes to discover the pathophysiology of ME/CFS during this period and discover biomarkers. Tests will include an exercise test to induce PEM, MRIs, cerebrospinal fluid tests, including a screen for autoantibodies to neural antigens, and an exploration of the gut and oral microbiome applying proteomics and metabolomics approaches.

Phase II of the trial will be open to a larger group of participants. This phase will validate biomarkers found in Phase I.

Phase III of the trial will focus on immunomodulatory agent, such as Ampligen, which can target the biomarkers found in Phase I.

Some questions raised by the audience concerned how NIH would incorporate patient input, what steps were being taken to educate physicians and medical students, and what kind of immune tests would be performed.

Dr. Avi Nath [42:38]: As some of you know, the National Institutes of Health has had a long-standing interest in chronic fatigue syndrome. In December of 2014, NIH sponsored a Pathways to Prevention workshop to advance research on ME/CFS. In September of 2015, Dr. Francis Colllins, the director of NIH, tasked the intramural program to develop a research protocol to study the illness using the unique resources that are available at the intramural program.

The relationship to infections to the onset or ME/CFS and the large body of literature identifying a variety of interesting but inconsistent immune abnormalities in these patients provide a rationale for further studies of immune regulation. For example, two studies from a group in Norway showed delayed clinical improvement in patients following treatment with rituximab, which is a monoclonal antibody that depletes B cells. However, these studies were small, and the immune profiles were not measured in these patients.

Patients with ME/CFS can be associated with a variety of precipitating factors. Our studies will be focused on a defined subset of patients who have a viral illness at onset of their illness. These patients are likely to have quite similar immune profiles. Our hypothesis is that post-infectious ME/CFS is triggered by a viral illness that results in immune-mediated brain dysfunction. To address this we have proposed a three-phase study.

The first phase is a cross-sectional study which will define the phenotype and pathophysiology of the disease. Phase two will validate the biomarkers in a longitudinal study. And phase three will be an early intervention trial to target the biomarkers identified in phase two.

The first aim of the phase one study is to define the clinical phenotype using in-depth assessments of all domains of the illness. [slide] Aim two of the study is to define the physiological basis of fatigue using functional MRI scan of the brain to define the brain circuits involved; do detailed metabolic studies in a metabolic chamber, and so transcranial magnetic stimulation as well as very detailed autonomic testing. Each of these tests will be performed before and after exercise.

The third aim of the study is to conduct a detailed immunological study in blood as well as cerebrospinal fluid, including a screen for autoantibodies to neural antigens. We will also fully explore the gut and oral microbiome and apply proteomics and metabolomics approaches to the cerebrospinal fluid.

The fourth aim of the study will utilize a variety of novel approaches to explore whether cells or serum from patients can be used to experimentally reproduce some of the features of the illness. We will determine if there is an inherent metabolic abnormality in neurons derived from stem cells and culture from these patients and if exposure of spinal fluid will induce the functional abnormalities in these cells.

We will also generate humanized mice using blood cells and determine if the clinical phenotype can be reproduced in these animals. If these experimental systems are able to reproduce the clinical or biologic abnormalities seen in these patients, it would be a major step towards identifying the cause and the pathophysiology of the illness, and for developing a variety of treatment approaches to these patients.

For the purpose of our phase one study, we plan to recruit patients primarily from well-characterized cohorts, particularly the CDC’s MCAM study. Selection criteria will include documentation of the acute onset and duration of fatiguing illness for more than six months but less than five years. All patients will have post-exertional malaise and full criteria of the 1994 research case definition and the Canadian Consensus Criteria. The study population will include 40 post-infectious ME/CFS patients, 20 healthy controls, 20 post-Lyme patients who are asymptomatic, that means they do not have fatigue, and 20 patients with functional movement disorders.

These studies are still being refined and rely on the talent and expertise of a large number of investigators listed here. I would particularly like to thank Dr. Brian Walitt, who is the lead clinical investigator of this study at NIH and Drs. Unger and Lipkin as members of the executive committee for their valuable advice.

______________________

Q&A [49:36]

Q: Why isn’t the CDC/NIH as a whole bringing pressure to bear on researchers and educating treating physicians to use far more extensive and detailed survey instruments and be far more precise in their description of the symptom presentation and pathogenesis?

Unger: I think that we are publicizing the importance of using instruments to precisely characterize the illness and we are in the process of publishing the baseline results of the MCAM study which will absolutely specify the instruments we are using and how they can help in other studies. And I believe we have been working with NIH and we are going to be sharing a lot of the same instruments and approaches.

Nath: We are delighted to be able to share whatever information we have and to work very closely with the CDC as Dr. Unger mentioned to achieve those goals.

Q: Another of our viewers would like to know all the specific steps that are being taken to educate medical students in medical schools using the latest information from that 2015 Institute of Medicine ME/CFS report.

Unger: Okay, well, we are… we have just started our medical student curriculum, as I mentioned through the MedEdPORTAL. This incorporates … so we started it before the 2015 but the educational curriculum that goes along with it gives the references from the IOM – the IOM report. In addition we have our collaborative process ongoing … or it’s just being started where we are trying to work with medical educators to find out what kind of materials they want and can easily incorporate into their classes. The advantage of the MedEdPORTAL is that it is online and it is free for faculty and actually medical students actually can have access to it as well. So we think that will be a useful start. The collaborative work group is what we hope will also be giving us advice as to what would be most helpful.

Q [Wilhemina Jenkins]: Dr. Nath, could I ask you to be a little more detailed about the patient advisory committee, how you intend to incorporate patient input into the NIH study? And could I also ask, I don’t know if you have the answer to this, about external funding from NIH to other researchers on the outside, possibly through RFAs that might be developed.

Nath: So, firstly I think input from the patients is absolutely critical for any disease that you want to study. They are ones who really experience the symptoms and live it – live it from day to day. As physicians whatever input we can get from patients is very important to whatever mechanism it is. Any physician will tell you that you learn a lot more from talking to patients than you do from reading any kind of textbook, journal, or whatever medical literature that is available. Careful listening to patients is absolutely critical. What that in mind, I grew up in the early AIDS epidemic , and I saw interactive with Act Up, and other patient forums whereby they had a great impact on the way the disease was handled, treated and moved the Federal government to make changes at every level. And so, we understand the importance of it, and there are efforts under way to put that advisory group together. So, you know, people who are senior to myself want to look at it from all perspectives and put together a proper group that will address both intramural and extramural teams. I think those efforts are under way and we are looking forward to that input.

With regards to external funding, again, that is beyond my area of authority and so I know there is a lot of interest in being able to make that happen. A lot of advocacy groups have approached NIH with that effort. I think the heart is in the right place and all those things will be done. I think it’s probably just a matter of time before you see all these things happen. But there is no lack of interest in achieving those goals.

Q: I'm Steve Monroe, Associate Director for Lab Science and Safety. I have a question for Dr. Nath. Given the consensus of the role of immune dysregulation and the symptoms of the disease, can you elaborate a little bit on the kind of functional immune assays that you are projecting to do with the upcoming study.

Nath: I’ve put together a panel of really outstanding immunologists to guide me. Although I do consider myself to be a neuroimmunologist, every immunologist is not the same. There are people who specialize in B-cells, and T-cells, and NK cells, and so on and so forth. So what I did was I called on Dr. Neal Young, who is an expert immunologist at NIH and Ronald Germain, who is a National Academy of Science member, and so we sat and discussed various kinds of things. I think what we’re going to do is we’re going to collect a lot of lymphocytes both from blood and from CSF [cerebrospinal fluid]. Initially, we’ll be storing them and what we’ll be doing is looking at cell-free fluid in the CSF and the serum for not just a small number of cytokines, actually 1,500 lysates, analytes. But we want to be very comprehensive and I have developed a proteomics assay in my own lab which will look at about at least 2,500 proteins. So when we look at the composite, I think that it will be very clear to us what cell types may be dysfunctional in these patients and how we can subgroup those individuals, and that will then allow us to go back and say, well, this looks like an NK cell function, let’s look at it, or this looks like a B-cell, because there are innumerable amounts of very time-consuming tedious assays for each cell type that you could potentially do on interactions between cell types. Instead of doing that at the get-go and everything you could possibly think , I think that’s a good screening tool, and then we can focus on the real aspects that we think are really dysfunctional.

Q: Do you think primary care providers can offer appropriate services to chronic fatigue patients or would it better for them to refer to specialists?

Komaroff: Yes, I think primary care providers can provide adequate services, particularly if they have people in ID, neurology backups when something doesn’t add up. But primary care providers need to be better educated than most are currently.

Lapp: I would agree with that and as a primary provider myself, and former family physician and internist and pediatrician, we’re at the forefront. The family physicians, the family doctors, are the ones who really see the majority of these cases first, not the specialists. So, as Tony [Dr. Komaroff] has pointed out it’s very important for these providers to be educated and know how to recognize the patients when they walk in the door. I should point out from previous studies done by the CDC that not only the primary providers but also the mid-level providers are doing a lot of the diagnosing and initial treatment of patients too. I think it is very important to address that group of individuals.

I would like to say that since the IOM report came out and the P2P, that we’ve seen a great deal of movement from the government. The patients always want to hear that, that there is something being done. From my perspective, working with this wonderful group, I’ve seen a lot of movement on behalf of the CDC and the National Institute [sic] of Health and even some positive statements from Dr. Francis Collins, who seems to be supporting a movement for more research into chronic fatigue syndrome.

Q: I’m Brenda Robertson, and I’m a nurse at Emory and Grady. My background is community health and divinity. And I want to know if there is anyone at the CDC or NIH or beyond looking at research into environmental triggers, such as the chemical loads that have been added to the food industry since the ‘70s and ‘80s, like phosphates, fructose, citric acid, and I wonder if anyone’s looking at that as serious triggers because this is a widespread illness.

Unger: We don’t have a specific focus on that. We are aware that there are environmental triggers in some patients, but it is something that we have in mind, but we don’ t have an active program in that right now.

Nath: At the intramural program we don’t have that kind of expertise. Our focus will really be on immune dysfunction. But the sample will certainly be stored. Once the extramural community gets involved, that have expertise in those areas, we would be delighted to work with them and provide them whatever resources we have in patient samples.

Last month's CDC Grand Rounds on Chronic Fatigue Syndrome featured presentations by Dr. Charles Lapp, Dr. Elizabeth Unger, Dr. Anthony Komaroff, and Dr. Avindra Nath. A short Q&A session followed the final presentation.

The full transcript of Part I is below. I have included a brief summary of the first three speakers, along with my commentary, at the top.

(Part II will cover the fourth speaker, Dr. Nath, as well as the Q&A session that followed the presentations.)____________________

Dr. Charles Lapp

Dr. Lapp's talk centered on the presentation of the illness, which he characterized as abrupt (developing over a few hours or days), with waxing and waning progression, and usually following an infection. He stressed that the disease could be devastating in its severe form, and frequently occurred with comorbidities. To diagnose the disease, Dr. Lapp recommended taking a complete history, including "psychosocial factors," as well as ruling out overlapping illnesses with exclusionary tests.

Dr. Lapp did not cover treatment, but rather presented his "four pillars of management": Education, Behavioral modification, Pharmaceutical management of symptoms, such as antidepressants, and Non-pharmaceutical interventions, such as exercise.

In this final section of his talk, Dr. Lapp's suggestions fell afoul of the observations of many patients, as well as other expert physicians. Intolerance of antidepressants, especially the tricyclics, has been noted by other physicians, including Dr. David Bell, whom Dr. Lapp cited in his presentation. According to Dr. Bell, a bad reaction to tricyclic antidepressants was virtually diagnostic of ME/CFS. Antidepressants have also been the most consistently negatively rated class of pharmaceuticals in several patient surveys, including a large survey conducted by the ME Association, and a smaller survey conducted by ProHealth.

Dr. Lapp's recommendation of graded exercise also flies in the face of patient experience. There is no evidence that graded exercise benefits ill patients, and plenty of proof that it causes harm. Yet doctors who should know better seem to feel that by not taking exercise their patients will get worse. Dr. Lapp's suggestion to "begin with five minutes" makes very little sense, because a patient who cannot spontaneously walk for five minutes is certainly too ill to begin any exercise program, however innocuous seeming. This was a disappointing end to an otherwise good overview of the disease.____________________

Dr. Elizabeth Unger

The next presentation was by Dr. Unger of the CDC, who reviewed some facts about ME/CFS, based on the CDC's own studies. Because she did not draw on outside sources, her portrayal of the disease was somewhat skewed. For example, Dr. Unger stated that "compared to healthy controls, persons with CFS had more exposure to significantly more stressors and are likely to have a higher allostatic load, that is, a measure of the physiologic consequences of chronic neuroendocrine response to stress."

The "stress" theory was one espoused by Dr. Stephen Straus, and by others who adhere to "psychosocial" models of causation. However, the assessment of pre-illness "stress" in ME/CFS patients is retrospective, which means it is inherently unreliable. The only reliable way to gauge "stress" as a factor in the development of an illness is to start with a population that is unstressed, introduce "stress," and see how many develop the disease. Until that is done for ME/CFS, "stress" cannot be included as an etiological factor.

The claim that "stress" plays a role in the development of ME/CFS is also contradicted by Unger's own study, which found that ME/CFS patients are as emotionally and psychologically sound as healthy controls, in spite of being very ill. If stress were a significant factor in the development of the illness, how is it that these ill patients - who are the most stressed of anyone - are able to cope so well?____________________

Dr. Anthony Komaroff

The third presentation was by Dr. Komaroff. He was asked to briefly summarize the IOM report, the P2P workshop, and the AHRQ review.

Dr. Komaroff stressed that the reports had found considerable evidence that ME/CFS is a biological illness. The IOM panel concluded that “ME/CFS is a serious, chronic, systemic disease that often can profoundly affect the lives of patients” and that ME/CFS is not, as many physicians believe, a psychological disorder.

The P2P report concurred in this and called specifically for research on the possible role of herpes viruses in ME/CFS. He then described the IOM's new case definition for SEID. (Scroll down to Dr. Komaroff's presentation to see the slide.) Although Dr. Komaroff did not dwell on the AHRQ report, he did mention that it stressed the need to test the IOM's case definition before adopting it.

In his discussion of the IOM's new case definition, Dr. Komaroff touched on the origins of both the original case definition proposed by the CDC and the name, chronic fatigue syndrome. "As a member of that group," he said, "I would note that we were all focused on developing a case definition. No one really thought about the name, and when someone proposed the name chronic fatigue syndrome, people said “Why not?” That was a big mistake.

Dr. Komaroff's review of the IOM report was thorough and accurate. However, he made an interesting comment when discussing the case definition for SEID. He said it was "shorter and simpler" (then contradicted himself by saying it was not simple), but that it was "the best we can do."

In light of the long track record held by the CCC, it is puzzling that Dr. Komaroff should say the SEID case definition is "the best we can do." (Obviously, experts in this illness have already done better.) By all accounts, the case definition for SEID is far too simple, and likely to include people with a number of other illnesses (including depression). Perhaps, Dr. Komaroff's apparent blind spot concerning the CCC was due to his involvement with the devising the original CDC case definition, which has since proved inadequate._______________________

On February 16, 2016, the CDC hosted a one-hour session on ME/CFS. Featured speakers included Dr. Charles Lapp, Dr. Beth Unger, Dr. Anthony Komaroff, and Dr. Avi Nath, who is heading the NIH study on ME/CFS. The session was introduced by Dr. Harold Jaffe, CDC Associate Director for Science.

Dr. Jaffe: Chronic Fatigue Syndrome is an important public health problem. Though many questions about the disease remain to be answered, we know that the disease is real, and that patients suffer greatly. Furthermore the economic impact of the disease is felt across the country. Chronic Fatigue Syndrome is a biologically based illness that affects individuals in nearly all aspects of their lives, significantly affecting their ability to work and support their families. Sadly, studies show that patients experience significant barriers in terms of receiving appropriate health care. This needs to change. We need to enable health care providers to better recognize and offer treatments for this condition.

Today we will learn that while there is no cure, there are management and therapeutic advances that can help patients. We need biomarkers to help make the disease more clearly diagnosable. We are aware that just the name “chronic fatigue syndrome” is imperfect in many ways, and can be unhelpful to clinicians and patients. However, we should not let legitimate arguments about nomenclature impede our scientific progress. CDC’s approach to reducing CFS morbidity includes working partnerships with clinical research experts, patient advocacy groups and other governmental agencies. At a time of unprecedented attention to this profoundly disturbing condition, CDC is committed to the broad outreach and clinical education efforts, of which this session is just one part. Again, the message is CDC is in this for the long run, we are not going to wait.

____________________

Dr. Charles Lapp [4:23]: Let me start by saying that in 1991 one of my colleagues, David Bell, wrote a book entitled “The Disease of a Thousand Names.” That title exemplifies the confusion we have about this illness. The signs and the symptoms are so general and so diverse, that chronic fatigue syndrome mimics many other disorders and has earned numerous monikers over the years, including Royal Free Disease, Iceland Disease, Tapanui Flu, “Yuppie Flu” (by the way, that came from the eminent medical journal, Rolling Stone Magazine), Myalgic Encephalomyopathy, Chronic Fatigue and Immune Dysfunction Syndrome, SEID (Systemic Exertion Intolerance Disease). For this presentation, I will be using the more common name chronic fatigue syndrome, which was chosen because 100% of the study’s subjects experienced an unusually severe and persistent type of fatigue.

There is no explanation why individuals contract chronic fatigue syndrome, but we do know that the majority of cases occur acutely over hours to days, and typically follow a bacterial or viral-like illness.

Let me introduce you to a typical case. This is an actual clinical case from my practice.

Jane was a 37-year old internet technologist for a community bank. She had been physically active in sports and had been working out and had been maintaining her own household when she contracted a flu-like illness in 2011. She was bedbound at first, and very slow to recover. Within days she noticed an unusual fatigue after minimal activities, then insomnia, then achiness in the joints and generalized muscle pain and weakness.

She soon found it difficult to recall recent conversations and events. Reading concentration was limited and she had trouble comprehending what she had read, or seen on TV. She would search for words, lose her train of thought, and friends would sometimes have to finish sentences for her. Sleep had always been good but now she was restless at night, and would awaken unrefreshed, even after many hours of bed rest.

She felt stiff and sore and foggy, and for an hour or two after awakening, she noticed dizziness or light-headedness on getting up quickly. On a couple of occasions she saw stars, but no tunnel vision and no syncope. Now she was unable to keep up the house, and she had to rely on friends and family to help her with the cleaning, laundry, and shopping.

She would attempt to keep up at home and at work, but exertion would inevitably make the symptoms worse, and if she exerted too much she would end up sick and chair bound for one or two days afterward. An evaluation by her primary care physician revealed rather low blood pressure, but there was no immediate orthostatic blood pressure drop and otherwise the examination was unremarkable. Blood work was unremarkable.

Having no explanation for her symptoms, despite the profound reduction in her physical abilities, Jane became anxious about her future and frustrated and discouraged as well.

This clinical case demonstrates all the key features of CFS:

Exertion intolerance and debilitating fatigue

Post-exertion relapse and malaise

New onset of sleep problems

Cognitive difficulties

Orthostatic intolerance

Symptoms wax and wane

Whole body flu-like arthralgias and myalgias, or widespread body pain

The cause of CFS symptoms is unknown, but there is an identifiable trigger in a majority of the cases that we see.

Precipitating Factors and Natural History

Symptoms develop over hours or days

Up to 85% report a trigger (bacterial or viral infection in 75% of cases)

Natural course of the illness is to wax and wane

Unpredictable onset and severity of symptoms, many relapses occur spontaneously and last for an indefinite period of time, which make it difficult for a person with CFS to plan ahead, or function on a regular, predictable or sustained basis

Most adults do not return to their pre-illness level of function, total recovery is uncommon

Individuals with CFS are also more likely than the general population to suffer comorbidities such as fibromyalgia, irritable bowel and bladder, Sjogren’s, Ehlers Danlos syndrome, and several other medical conditions. Sadly, it is an “invisible illness,” and to the casual observer patients appear entirely normal and healthy, but the gravity of the disease is such that it totally changes one’s lifestyle, and the lives around that patient as well.

One of my patients pointed out to me, “This illness can take away everything, your dignity, your livelihood, your family, your marriage, and even all of your money.”

As you can imagine, the symptoms of chronic fatigue syndrome overlap with many disorders, including depression, MS, systemic lupus, endocrine disorders, hepatitis, and many other illnesses. So, in order to confirm a diagnosis of chronic fatigue syndrome one needs to exclude disorders that could plausibly explain the exertion intolerance and the other symptoms. The essentials of an evaluation include a thorough history, a thorough psychosocial history, such as a history of dysfunctional childhood, prior verbal or physical abuse, substance abuse, a complete physical examination, a mental health examination. Such an evaluation typically takes about 30 minutes to 60 minutes in my office.

Lastly, it’s recommended to obtain basic screening lab tests. They may include a CBC with differential, sed rate, urinalysis, thyroid tests, metabolic panel, glucose, BUN, creatine, electrolytes, and other lab tests to rule out other possible sources of fatigue such as infection, autoimmune disorders, endocrine or hormonal problems, celiac disease, etc . The results of these tests are usually unremarkable.

The IOM recommends making the diagnosis actively. That means making the diagnosis promptly, even before one excludes other plausible causes. The IOM criteria for SEID provide a brief and simple method for diagnosing CFS. But many clinicians, including myself, corroborate the diagnosis with established instruments such as the Fukuda criteria of 1994, or the Canadian Consensus Criteria.

Making the diagnosis promptly reduces anxiety and uncertainty for the patient and reduces medical costs, because numerous exclusionary lab tests and procedures would not be needed.

Let’s consider the prognosis for these patients. In a systemic review of the natural course of CFS, a median of 39.5% of adults with CFS improved and a median of 5% experienced full recovery. The likelihood of recovery decreases with baseline illness severity, duration of the illness, and the presence of comorbid psychiatric conditions.

Children and adolescents fare somewhat better, with one paper reporting 60% recovery at five years, and 88% at twelve years after the onset of their illness. In another longitudinal study of 25 adolescents with CFS compared to 25 controls, 80% of the patients had remitted over a course of 25 years, but many still reported more impairment than the controls.

The management of chronic fatigue syndrome can be briefly summed up by these four pillars:

Education – Reliable information should be provided to the patients, and an excellent source is online at the CDC.gov/cfs website.

Behavioral modification is effective to limit depression, anxiety, and abnormal coping mechanisms, such as denial and escape avoidance.

Pharmacologic therapy – Sleep disruption and pain are usually addressed first, and may require consultation with a sleep specialist or pain management group. We generally avoid narcotic medications, but helpful therapies include tricyclics such as amitriptyline, cyclobezaprine, the NSRIs, such as duloxetine and milnacipran, anti-epileptic medications like pregabalin. The next step is to address severe symptoms and comorbidities that the patients suffer.

Non- Pharmacologic therapy might include Epsom soaks, hot and cold packs, liniments, massage, osteopathic manipulation, acupuncture, and the like. Another form of non-pharmacological therapy is staying active, but not too active.

We recommend starting with very low levels of activity, and proceeding slowly. Brief intervals of activity should be followed by adequate rest in order to avoid a flare of symptoms or to avoid the post-exertional malaise. Consider beginning to active stretching and range of motion exercises against gravity. Then follow with light resistance training with light weights for example, or elastic bands. We then advance to certain types of aerobic activities such as tai chi, yoga, walking, bicycling, or aqua therapy. To avoid flares, patients should limit activity by time, say less than five minutes per day to start, and limit the number of repetitions, and if they experience any excessive fatigue, reduce the amount of time, or the number of repetitions.

In summary, we can find chronic fatigue syndrome in both pediatric and adult groups. It typically has a preceding medical event, often infection. Patients benefit from earlier comprehensive evaluation and diagnosis. The disease can have a severe impact on quality of life, but improvement and recovery are certainly possible. There is no curative therapy, but graded exercise and some types of pharmacotherapy can be of great benefit. Thank you.

​Beth Unger [17:42]: When designing a public health approach to illness, one of the first steps is to understand the epidemiology of the condition. For CFS the answer to this question is difficult because there is no simple test to make the diagnosis, and findings will differ depending on how the patients are identified. For example, self-report compared with clinical assessment, as well as where the study is conducted. For example, in clinics compared with the population as a whole. Population-based studies that include clinical assessments are generally considered to give the most accurate estimates. But these are complex and expensive. Extrapolating estimates from three U.S. population-based surveys to the country as a whole, we can estimate that at least one million Americans suffer from CFS. Most patients identified in the population surveys have been ill longer than five years, and only about half of those affected continue to seek medical care.

In addition, only about 20% of those identified as CFS have been actually diagnosed by a physician. This emphasizes the need for more physician education about this illness.

These studies indicate that CFS is three to four more times more common in women than in men. Persons of all race and ethnic backgrounds are affected, and there is a disproportionate burden of CFS in minority and socioeconomically disadvantaged groups.

The highest incidence of prevalence is in 40-50 year olds, but the age range is broad and includes children and adolescents.

It’s important to understand the economic impact of the illness and barriers to healthcare utilization. Patients, their families, and society all bear significant costs associated with CFS. These include direct medical costs of provider visits and medications, and indirect costs of lost productivity.

In the U.S., the estimated annual cost of direct costs is between nine and fourteen billion dollars. And nearly one-quarter of these expenses is paid directly by the patients and their families.

The estimated annual cost of lost productivity is between nine and thirty-seven billion dollars.

When CFS occurs before age 25, the ability of patients to complete their education is significantly impaired. Inability to achieve their full education potential can have a lifelong impact on earning potential.

CFS patients face significant barriers to receiving appropriate healthcare. A population-based study in Georgia found that 55% of persons with CFS reported at least one barrier to healthcare. Finances prevented 10% from seeking care. This is twofold higher than the population average found in the 2005 national health interview survey.

While the cause or causes of CFS are unknown, studies have identified some factors that are associated with the illness. Risk factors may suggest avenues to explore to discover causes, or to develop interventions. Infections have been linked to CFS because patients often report an acute onset after a flu-like illness that does not go away. And some patients have a history of frequent infections prior to their illness. Epidemiologic studies do not support association with any single pathogen.

Post-infectious fatigue, that is, failure to recover from a documented infection occurs in about 10% of patients with a variety of viral and non-viral pathogens, such as Epstein-Barr virus, Ross River virus, Q fever (that is Coxiella burnetii), or giardia.

The severity of the acute infection is most predictive of subsequent illness, and there is no evidence of an unusual persistence of infections in those who remain ill.

Compared to healthy controls, persons with CFS had more exposure to significantly more stressors and are likely to have a higher allostatic load, that is, a measure of the physiologic consequences of chronic neuroendocrine response to stress. They are also more likely to have metabolic syndrome.

These associations are unlikely to be specific to CFS, as stress is a factor in many chronic illnesses.

Twin and family studies support the contribution of both genetic and environmental factors in CFS. No specific genes have been identified, and a polygenetic explanation for increased susceptibility is most likely.

CDC recently shifted its focus from population-based surveys to studying CFS patients being cared for by clinicians with specialized expertise in CFS. Population-based surveys are helpful to identify the full spectrum of those affected and include a broad range of illness severity. Patients identified from clinics tend to have more severe illness. Most studies of CFS have been conducted in patients enrolled from single clinics and include small numbers of patients. Many intriguing findings have not been replicated, leading to the suggestion that heterogeneity of patients may contribute to this difficulty.

Our study is designed to document a comprehensive picture of CFS patients in multiple clinics, and to describe the approach that experts use to diagnose and manage their patients. We use standardized questionnaires to measure the major domains or characteristics of the illness. These questionnaires measure the level of function, pain, fatigue, type of severity of symptoms, and sleep.

We also collected medical history, family history, physical examination results, medications, and results of laboratory tests. We included the PROMIS instruments that were designed and validated by NIH to measure symptoms experienced in many different illnesses to allow comparison between illnesses. The SF 36 measures of function and multi-dimension fatigue inventory have also been widely used in a variety of conditions. Seven clinical sites have participated in this study, which was initiated in 2011. Five participate under the umbrella organization of the Open Medicine Institute Consortium. The clinicians participating are all well-known, respected experts in CFS and include one of our speakers today, Dr. Lapp. Their expertise is what gives credibility to the study.

We are very grateful to their patients who have agreed to be part of this study and have accepted the additional burden of completing the many questionnaires required.

We collected complete data of 471 patients in the baseline study. These were distributed fairly evenly across the clinics. The mean patient age was 48.2 years and the mean duration of illness was 14.3 years. Most patients were female and the vast majority were white. The mean BMI was 26.6. More than three-fourths of the patients had a college education and nearly all were insured.

While about three-fourths were unemployed, only 14% were receiving unemployment benefits.

There were statistical differences in the demographics between all the clinics in these measures, except the proportion not working.

The patients in these specialty clinics may not be representative of CFS patients in other healthcare settings, as they were all highly educated and with sufficient socioeconomic support to be able to navigate their way to these specialized centers. Most patients had been seen and evaluated by more than one physician prior to coming to their clinic.

We found significant heterogeneity in the patients overall, but there were very few differences between clinics in these average measures. [Slide] The important feature to note is that the patients show significant functional impairment, particularly for vitality and physical functioning, but there is a relative preservation mental health and role emotional.

The data in our study confirms the seriousness of this illness and the extent of impairment experienced by patients with CFS. We are continuing this study to collect longitudinal measures of illness characteristics and to enroll groups of patients that have been understudied, specifically pediatrics, severely ill or homebound patients, and patients within two years of onset of the illness. We are also enrolling healthy controls and ill comparison groups who may present similarly to CFS. In addition we are collecting blood and saliva on those enrolled so that they can be tested for biomarkers that have shown promise in smaller studies.

Results from this study will help to find patient subgroups that reflect different causes or that could suggest targeted therapies.

Finally, the data clearly show that the patients in these specialty clinics are highly educated with significant financial and social support that enable them to reach these expert physicians. Again, this emphasizes the need for dissemination of knowledge about CFS to the broader medical community.

It is clear that despite decades of work, CFS remains a challenge for clinicians. Patients have difficulty finding a compassionate and appropriate care. Physicians and other healthcare workers need evidence-based information about CFS. CDC has responded to this need by developing a series of continuing medical courses. In 2012 and 2013 we partnered with Medscape to present two roundtable discussions that were targeted to primary care physicians. These reached more than 22,000 physicians and more than 6,000 continuing medical education credits were issued. Currently, CDC has two free online courses available on the CFS website. These are accredited for physicians, nurses, and other healthcare professionals.

However, CFS is rarely covered in medical schools, and this leaves a vacuum of knowledge. So we’ve begun the process of developing standardized patient videos accompanied by educational curriculum for the MedEdPORTAL.

This is a free online service provided by the Association of American Medical Colleges. The materials are peer-reviewed and once approved are made available to medical school faculty free of charge.

Finally, CDC is continuing communication with the general public and advocacy community. An important part of this has been the introduction of patient-centered outreach and communication calls (PCOCA calls). These are one-hour teleconferences that are available toll-free in the U.S. They began in 2012 and are generally held twice a year. The format is that the CDC uses the first ten minutes to give an update on current activities of the CFS program, and then an outside expert or group of experts presents information on a topic of interest to the community. These talks generally last 35 to 40 minutes and are followed by answers to questions submitted to the PCOCA email. Topics have included identifying patients for clinical studies, exercise, infection and immunity in CFS, CFS and cognitive function, sleep research and CFS, Stanford’s research program, and self-management strategies in CFS.

We are grateful to all the experts who graciously gave up their time to share their insights with the patients and their families.

Most recently, we’ve begun a new initiative to include broad stakeholder collaboration into developing educational materials. Including the viewpoints of patients, medical professional organizations, medical educational organizations, expert clinicians and government agencies will help assure the quality and usefulness of these products, and help facilitate dissemination in the medical community at large.

Our first focus will be modification of the CDC CFS web page to incorporate recommendations of the Institute of Medicine. I’d now like to turn the podium to Dr. Komaroff.

Dr. Anthony Komaroff [31:07]: I was asked to speak about three recent authoritative reports , in which experts, many of them from outside the field of chronic fatigue syndrome evaluated the evidence that’s been published.

The first is from the Institute of Medicine of the National Academies of Science, which issued a 300-page report in which the panel reviewed the literature of nearly 9,000 published articles, and concluded that ME/CFS is a biologically based illness, and proposed a new case definition as well as a new name.

The second report was from the NIH, which held a Pathways to Prevention conference with a follow-up report drawing similar conclusions about the biology of ME/CFS.

Finally, the federal Agency for Healthcare Research and Quality (AHRQ) commissioned an independent review that focused on diagnosis and treatment.

The Institute of Medicine report first addressed the question of the scope and seriousness of ME/CFS, drawing heavily I might say on published studies from the CDC. The Institute concluded that between 800,000 and 2.5 million Americans have the illness. The Institute also agreed that the costs of the illness to society were substantial, as much as 51 billion dollars annually.

Based on their review the Institute panel concluded that “ME/CFS is a serious, chronic, systemic disease that often can profoundly affect the lives of patients” and that ME/CFS is not, as many physicians believe, a psychological disorder.

Then the Institute turned to an important question: Given that ME/CFS is defined exclusively by subjective symptoms, symptoms that any human being can say they have, are there any confirmatory, underlying objective biological abnormalities in these patients compared to healthy subjects and compared to patients with other fatiguing illnesses? That includes comparison with the biological abnormalities in some psychiatric illnesses.

The Institute of Medicine found considerable evidence of underlying neurological abnormalities as reflected by many different diagnostic technologies. Those singled out for special mention by the panel included slowed information processing, problems with white matter integrity, neuroinflammation, impairment of working memory, HPA axis abnormalities, and autonomic abnormalities. The NIH report was in general agreement with the Institute on this issue.

The Institute of Medicine also concluded that there were considerable immunologic abnormalities in patients with ME/CFS. They highlighted two as being particularly well substantiated: impaired natural cell killer cell function that correlated with illness severity, and increased cytokine levels in blood, suggesting a state of chronic immune activation. The Institute of Medicine noted that many, but not all patients, with ME/CFS reported that their illness began following an acute infectious-like illness characterized by fever, myalgias, respiratory, GI, neurologic symptoms, along with severe fatigue, an illness from which patients say they have never recovered.

Indeed, the medical literature includes many reports of post-infectious fatigue syndromes linked to well-documented acute infections. For this reason many have wondered if at least some cases of CFS may be initiated or even perpetuated by infection. The Institute panel concluded that there is “Sufficient evidence suggesting that ME/CFS follows infection with Epstein-Barr virus and possibly other specific infections, viral, bacterial, and possibly protozoal.”

NIH report concurred in this and called specifically for research on the possible role of herpes viruses in ME/CFS.

There have been several case definitions proposed for this illness. Perhaps the most widely used is the case definition developed under the leadership of the CDC and published in 1994. The Institute of Medicine panel proposed a new case definition that it hoped would be simpler and shorter, easier to apply consistently across patients, likely to result in fewer false negative and false positive classifications, and likely to be a better predictor both of response to therapy as well as prognosis.

The key elements of the proposed new case definition by the Institute are: 1) Post-exertional malaise, defined as a prolonged worsening of a patients’ baseline symptoms after physical or cognitive exertion, or orthostatic challenge, exertion, or stress, 2) Unrefreshing sleep, defined as regularly feeling unrefreshed after sleeping many hours, 3) Cognitive impairments of a side variety of types that are made worse by exertion, effort, stress, or time pressure, and 4) Orthostatic intolerance, or symptoms that worsen upon assuming and maintaining and erect posture and that are improved by lying down or elevating the feet. [Slide]

The IOM case definition is shorter, but it is not simple. But at the moment I think it is the best we can do.

The new case definition, like most that preceded it, does not include laboratory studies. ME/CFS remains a multi-system disease for which we do not yet have a single diagnostic biomarker. Indeed, until there is a gold standard pathological finding for the illness, I don’t think it will be possible to test the accuracy of any case definition. It will, however, be possible to compare the performance of different alternative case definitions against each other in large numbers of patients, and that already is underway. As pointed out by the AHRQ, a new case definition does need to be tested empirically to verify that it is superior to its predecessors.

The name chronic fatigue syndrome was coined in 1988 by a group convened by CDC. As a member of that group, I would note that we were all focused on developing a case definition. No one really thought about the name, and when someone proposed the name chronic fatigue syndrome, people said “Why not?” That was a big mistake.

Many of the patients and clinicians believe that that name, chronic fatigue syndrome, trivializes and stigmatizes this often devastating illness, and I certainly agree.

Many different names have been proposed. The new name proposed by the Institute of Medicine, Systemic Exertional [sic] Intolerance Disease [note: SEID stands for Systemic Exertion Intolerance Disease], has some merits. It focuses on a core component of the illness. But I think it’s too early to determine whether this new name is going to be widely adopted by both the clinician and patient community.

In summary, the Institute of Medicine and the NIH reports conclude that patients with ME/CFS have underlying objective biological abnormalities, that their symptoms are not imaginary. However, none of these biologic abnormalities is so sensitive and specific that it constitutes a biomarker, a diagnostic test.

ME/CFS is an important disease causing great suffering to many individuals and their families, and billions of dollars in lost productivity to society. Finally, more research is urgently needed and indeed the NIH along with CDC has recently announced its intention to expand its focus on this illness, particularly in its intramural program as described next by Dr. Avi Nath.

A few days ago, Griffith University, located in Queensland Australia, announced that it had developed a screening test for ME/CFS. Dr. Donald Staines, whose first article about ME appeared as early as 1985, has been researching ME/CFS for over a decade. Likewise, Dr. Sonia Marshall-Gradisnik, Dr. Ekua Brenu and fellow researchers have pursued the underpinnings of ME/CFS with studies that have revealed several markers of immune dysfunction, including natural killer and B-cell abnormalities, autoimmune markers, and increases in inflammatory cytokines, among other findings.

Dr. Marshall-Gradisnik believes that a biomarker for ME/CFS can be found in micro RNAs (miRNA) - tiny RNAs associated with gene expression, and which regulate many biological processes in plants, animals, and even viruses. Marshall-Gradisnik's team was the first to identify circulating miRNAs from ME/CFS patients. They found three distinct miRNAs that might serve as biomarkers.

Dr. Marshall-Gradisnik and her team have applied for three patents for biomarkers potentially useful in diagnosing ME/CFS. If the patents are approved, there may be a commercially viable test in the offing. But, before a test can be developed and marketed it has to be successfully used on a significant portion of the patient population. So far, no large-scale studies have been done. Hopefully, with the recent attention that has been drawn to the plight of ME/CFS sufferers in Australia, Griffith University will get some backing to extend its research.

____________________​Screening test for chronic fatigue syndrome on its way

Press Release: Griffith University, March 1, 2016. Ground-breaking research at Griffith University into Chronic Fatigue Syndrome (CFS) is leading the way for the development of a new screening tool for the condition.

The research team from the National Centre for Neuroimmunology and Emerging Diseases (NCNED), Menzies Health Institute Queensland, has identified new markers that can be used to screen patients and is now looking to partner with diagnostic companies to bring a test to market. The screening test is expected to benefit all those with symptoms of the condition.

“Over the last four years, with support from the Queensland Government and philanthropic donors, we have identified unique markers in CFS patients,” says Professor Marshall-Gradisnik.

“This screening test may be expected to become a laboratory standard to provide more certain, and cost-efficient, diagnosis for CFS. Currently patients may be undergoing a range of tests to diagnose for CFS which incurs a significant cost to the health care system.

“CFS, also known as myalgic encephalomyelitis (ME), affects up to 400,000 Australians, many of whom are housebound or bedbound. Patients are isolated and further stigmatised by disbelief of their condition.

“This illness has traditionally been difficult to diagnose, meaning that people can go for months without getting the care and attention they require. We are confident that the new screening test currently in development will provide efficient and increasingly accurate screening for people with CFS. This test may also be used to monitor and track the progression of their illness,” says Professor Staines.

Innovative research

Developing this screening test and engaging potential diagnostic companies reflects the innovative research being undertaken to deliver better health outcomes for CFS patients in Australia.

Awareness and support of CFS is currently gathering momentum in Australia, with a recent Senate Estimate Committee highlighting the requirement for increased research and funding regarding the condition.

There are thousands of people with M.E. (Myalgic Encephalomyelitis) in Ireland. At the very best, we receive only symptom management from our doctors, that's the best they can do for us. There is a drug, Ampligen (Rintatolimod), for the treatment of M.E.

Ampligen has been successfully trialled in the U.S.A. for the last two decades. Many M.E. patients have gone into FULL REMISSION with this drug.

We are asking the Minister For Health to make Ampligen available to us.

M.E. is an neurological illness as defined by the WHO (World Health Organisation). It affects all systems: neurological, immune, endocrine, gastrointestinal, musculoskeletal, etc. The symptoms can vary from mild, moderate, severe to very severe. It can be remitting/relapsing or progressive. Some people spend their days in a darkened room, unable to tolerate light or sound. Some are tube-fed. Others are mildly affected.

My name is Noreen Murphy. I have M.E. for over 29 years. Initially, I was very severe, then moderate for a number of years but have Severe M.E. for past few years.

HIGHLIGHTSFebruary 28 - Ampligen should be available for those sickened by myalgic encephalomyelitis. It is a reasonable treatment option to try and a way to return some to normal life again.February 23 - Any drug that's deemed safe should be made available to people with this illness. The pain and suffering never stops, I know this as I care for my daughter who's been ill for 28 years since the age of nine.February 16 - Petition has reached 500 signatures!February 11 - I have been on Ampligen on a cost-recovery, compassionate-care basis since 1999 (except for four years when I lost it); It made my immune biomarkers disappear and my viruses go dormant.. FDA has said in writing that there are no major toxicities. There are no other drugs specifically targeted to ME... show moreFebruary 11 - Petition has reached 100 signatures!February 10 - We are now live!

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About me:I'm a 25-year veteran of CFIDS. I know what it is like to be bedbound for long stretches of time. I also know what it is like to recover, and to relapse. But this blog is not about my personal experience. It is intended to be a resource - a collection of anything that might be helpful to the CFIDS community: book reviews, advice, CFIDS news, research, advocacy, opinion, who's who in our community, fundraising... and occasionally a bit of humor.

Disclaimer: I am not a doctor, which means nothing I write, no matter how sensible it may be, should be interpreted as medical advice.